Appendicitis

Question 1

Pathophysiology of appendicitis

Answer 1

• appendix is a small, thin tube arising from the caecum
• located at the point where the 3 teniae coli meet (teniae coli are the logitudinal muscles that run the length of the large intestine)
• there is a single opening to the appendix that connects it to the bowel, and it leads to a dead end

pathogens → trapped due to obstruction where the appendix meets the bowel

infection + inflammation

gangrane + rupture

when ruptures → faecel contents and infective material are released into the peritoneal cavity → this leads to peritonitis, which is inflammation of the peritoneal lining

Question 2

Risk factors of appendicitis

Answer 2

peak: age 10-20 years

• occur at any age but is less common in young children and adults over 50 years

Question 3

Where is the pain in appendicitis?

Answer 3

• typically starts as central abdominal pain that moves down to the right iliac fossa (RIF) within the first 24 hours
• eventually becomes localised in the right iliac fossa
• on palpation of the abdomen, there is tenderness (pain when touched) at McBurney’s point → specific area one third of the distance from the anterior superic iliac spine (ASIS) to the umbilicus.

Question 4

Apart from pain, what are the presenting features?

Answer 4

loss of appetite

N+V

Low-grade fever

Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF)

Guarding on abdominal palpation

Rebound tenderness in the RIF (increased pain when suddenly releasing the pressure of deep palpation)

Percussion tenderness (pain and tenderness when percussing the abdomen)

Question 5

What indicates a ruptured appendix?

Answer 5

rebound tenderness and percussion tenderness suggest peritonitis, potentially indicating a ruptured appendix

Question 6

Investigation/diagnosis?

Answer 6

• mostly based on clinical presentation and raised inflammatory markers
• CT scan can be useful in confirming diagnosis
• ultrasound → often used in females to exclude ovarian and gynaecological pathology. also useful in children where CT less appropriate due to radiation
• when a patient has a positive clinical presentation but negative investigations → perform a diagnostic laparoscopy to visualise the appendix directly

Question 7

Treatment of appendicitis?

Answer 7

Appendicetomy

Laparoscopic surgery → fewer risks and faster recovery time compared to an open surgery

Question 8

Complications of appendicectomy

Answer 8

• Bleeding, infection, pain and scars
• Damage to bowel, bladder or other organs
• Removal of a normal appendix
• Anaesthetic risks
• Venous thromboembolism (deep vein thrombosis or pulmonary embolism)

Question 9

What should be seen on blood tests?

Answer 9

Neutrophil predominant leucocytosis present in 80-90% of people